5 U.S. Code § 8903 - Health benefits plans

The Office of Personnel Management may contract for or approve the following health benefits plans:

(1) Service Benefit Plan.— One Government-wide plan, which may be underwritten by participating affiliates licensed in any number of States, offering two levels of benefits, under which payment is made by a carrier under contracts with physicians, hospitals, or other providers of health services for benefits of the types described by section
8904(1) of this title given to employees, annuitants, members of their families, former spouses, or persons having continued coverage under section
8905a of this title, or, under certain conditions, payment is made by a carrier to the employee, annuitant, family member, former spouse, or person having continued coverage under section
8905a of this title.

(2) Indemnity Benefit Plan.— One Government-wide plan, offering two levels of benefits, under which a carrier agrees to pay certain sums of money, not in excess of the actual expenses incurred, for benefits of the types described by section
8904(2) of this title.

(3) Employee Organization Plans.— Employee organization plans which offer benefits of the types referred to by section
8904(3) of this title, which are sponsored or underwritten, and are administered, in whole or substantial part, by employee organizations described in section
8901(8)(A) of this title, which are available only to individuals, and members of their families, who at the time of enrollment are members of the organization.

(4) Comprehensive Medical Plans.—

(A) Group-practice prepayment plans.— Group-practice prepayment plans which offer health benefits of the types referred to by section
8904(4) of this title, in whole or in substantial part on a prepaid basis, with professional services thereunder provided by physicians practicing as a group in a common center or centers. The group shall include at least 3 physicians who receive all or a substantial part of their professional income from the prepaid funds and who represent 1 or more medical specialties appropriate and necessary for the population proposed to be served by the plan.

(B) Individual-practice prepayment plans.— Individual-practice prepayment plans which offer health services in whole or substantial part on a prepaid basis, with professional services thereunder provided by individual physicians who agree, under certain conditions approved by the Office, to accept the payments provided by the plans as full payment for covered services given by them including, in addition to in-hospital services, general care given in their offices and the patients’ homes, out-of-hospital diagnostic procedures, and preventive care, and which plans are offered by organizations which have successfully operated similar plans before approval by the Office of the plan in which employees may enroll.

(C) Mixed model prepayment plans.— Mixed model prepayment plans which are a combination of the type of plans described in subparagraph (A) and the type of plans described in subparagraph (B).

Standard changes are made to conform with the definitions applicable and the style of this title as outlined in the preface to the report.

Amendments

1998—Par. (1). Pub. L. 105–266substituted “plan, which may be underwritten by participating affiliates licensed in any number of States,” for “plan,”.

1988—Par. (1). Pub. L. 100–654substituted “former spouses, or persons having continued coverage under section
8905a of this title,” for “or former spouses,” and “former spouse, or person having continued coverage under section
8905a of this title.” for “or former spouse.”

1986—Par. (4)(A). Pub. L. 99–251, § 102, amended second sentence generally, substituting “at least 3 physicians” for “physicians representing at least three major medical specialties” and inserted “and who represent 1 or more medical specialties appropriate and necessary for the population proposed to be served by the plan”.

1984—Par. (1). Pub. L. 98–615, § 3(3), substituted “employees, annuitants, members of their families, or former spouses” for “employees or annuitants, or members of their families” and “employee, annuitant, family member, or former spouse” for “employee or annuitant or member of his family”.

Amendment by Pub. L. 100–654applicable with respect to any calendar year beginning, and contracts entered into or renewed for any calendar year beginning, after end of 9-month period beginning Nov. 14, 1988, and with respect to any qualifying event occurring on or after first day of first calendar year beginning after end of such 9-month period, see section 203 ofPub. L. 100–654, set out as a note under section
8902 of this title.

Effective Date of 1984 Amendment

Amendment by Pub. L. 98–615effective May 7, 1985, with enumerated exceptions, and applicable to any individual who is married to an employee or annuitant on or after that date, see section 4(a)(2) ofPub. L. 98–615, as amended, set out as a note under section
8341 of this title.